Looking Back, Moving Forward: How Meaningful is Your Meaningful
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2013 Encore Health Resources
Encore Health Resources
Looking Back, Moving Forward: How Meaningful is Your Meaningful Use? An Encore Point of View
Kathleen Mrozek, Amy Thorpe, and Mike Grisaffe
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Looking Back, Moving Forward: How Meaningful is Your Meaningful Use?
ealthcare providers have been engaged in heroic efforts to bring about meaningful use of electronic health records (EHRs) since the 2010
passage of the Centers for Medicare and Medicaid Services (CMS) Incentive Program introduced as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The intent to promote the transition of healthcare from a fee-for-service to a fee-for-value world was apparent from the beginning. This paper reflects on the foundation that has been laid in Stage 1 of the meaningful use (MU) program, along with the challenging work yet to be accomplished as healthcare providers continue their journey to meaningful use of their EHRs.
Figure 1. Universe of the EHR. Its not only about Meaningful Useits about creating an
eMeasure foundation for the future
ncore contends that achieving meaningful use requires employing full lifecycle methodology, with the ultimate goal of realizing value-based
performance improvement. MU can be seen as foundational to establishing a platform for defining, calculating and reporting the 2014 electronic clinical quality measures (eCQMs), and achieving the Stage 2 goals and beyond. Successfully meeting meaningful use requires more than just setting up another IT project, checking off boxes, and receiving incentive payments. Rather, a compelling case can be made for adopting a strategic and programmatic approach to enable ultimate success over successive stages. It requires implementing a program with consideration of standardization, improved workflows, documentation at the point of care, interoperability, eCQMs as defined by multiple quality programs, and an auditable defense portfolio that provides evidence of the providers compliance and intent. A full lifecycle looks beyond the initial incentive payments. It employs a comprehensive approach that
closes the loop on every aspect of the program. It establishes the culture and business plans which support improved patient care outcomes and efficiencies necessary to survive in the new fee-for-value healthcare world.
Figure 2. Developing a full lifecycle approach to meaningful use requires integrating several key components.
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Where are we with Meaningful Use?
The MU Program was designed to encourage adoption of Certified Electronic Health Record Technology (CEHRT), and in that respect, progress has been made. Cumulatively, through June 2013, CMS has paid over $15.5 billion to eligible professionals (EPs) and eligible hospitals (EHs) through the parallel Medicare and Medicaid programs since 2011.1
More than 305,500 EPs and over 4,000 EHs have received incentive payments from the Medicare and Medicaid EHR Incentive Programs.
Nearly 3 out of every 5 Medicare and Medicaid EPs and about 8 out of 10 EHs have made a financial commitment to an EHR.
It was understood from the outset that simply converting from paper to electronic patient records would not guarantee better patient care nor enhance the experience of providing or receiving healthcare. For
this to occur, the use of electronic records would have to be meaningful. To support achieving meaningful, as outlined in Figures 3 and 4, the EHR Incentive Programs are staged with increasing requirements for participation: Data capturing and sharing, advanced clinical processes, and improved outcomes.3
Figure 3. Stages of Meaningful Use.4
The Stage 1 Final Rule focused on functionality related to capturing and reporting on structured data, implementing clinical decision support at the point of care and using the captured data for care coordination. This was all seen as foundational to the ultimate goal of providing evidence-based, patient-centered care. Now that the substantially more difficult Stage 2 requirements have been released, along with the 2014 edition EHR Certification Criteria, it is evident the foundation which was laid for the Stage 1 attestation will profoundly affect the ability of hospitals and providers to meet Stage 2 and the 2014 eCQM reporting requirements. It has become clear that adopting a strategic and programmatic approach is required to successfully implement advanced clinical processes in Stage 2 and achieve improved outcomes targeted for Stage 3.
Figure 4. Summary of Meaningful Use Criteria and Objectives by Stage5
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To adopt a programmatic approach, eligible hospitals and providers must be willing to invest the time, money and resources into meeting the spirit of the measures, by setting up systems, processes and workflows that serve to enhance the patient and provider experience.
What has been accomplished for achieving MU can also be leveraged by other quality-based initiatives such as Accountable Care and Value-Based Purchasing (VBP). In addition, the newly available structured data can support population health management, clinical integration and new payment models.
Taking a programmatic approach to achieving meaningful use can provide untold benefits in the long run. It requires a commitment from the organizations leadership for the creation and overall management of a value-based improvement program along with extensive change management.
ith MU Stage 2, it is critical to understand how approaches taken in Stage 1 profoundly affect an organizations ability to prepare and succeed in Stage 2, especially for some key differences.
Among the more challenging thresholds are CPOE, Problem List and Medication Reconciliation.
Clients who took the value-based approach at the outset are now in the lead with regard to successfully preparing for the Stage 2 requirements.
Increase of thresholds for utilization measures; physician engagement is critical
Change of eight menu set measures to core
Focus on portals and patient engagement
Removal of Clinical Quality Measures as separate objective
Increase of focus and expansion of eCQMs
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Problem List Medication Reconciliation eCQMs Vendor MU Reports Data Elements and Workflow Analysis Disparate Systems
The Journey to Meaningful Use Stage 2
How Have Organizations Approached Meaningful Use?
Choosing a Path As organizations began to prepare for their meaningful use journey, approaches varied widely. Gaining a solid understanding of the regulations was a common baseline; however, the path to achieving MU took different turns. All too often MU was seen as an IT project, and achievement was seen as a means to secure additional funding, which resulted in checking off the boxes with little input from end users. With this approach, implementations were fraught with workarounds, frustrated end users, challenges with meeting MU thresholds, and failure to achieve the foundational gains intended by CMS; not to mention, a higher potential for penalties as a result of random auditing.
Organizations who took the short route are now facing Stage 2 with increased thresholds, a focus on sharing
data and engaging patients, increased focus on eCQMs, and realizing they have significant work ahead. The MU experience has proven to be a difficult task, even for organizations who have been pioneers in the use of HIT, such as Vanderbilt University, who rolled out its homegrown EHR back in 2001. Margaret Head, COO and CNO for the Vanderbilt Medical Group told attendees at the AMA Group Association's annual conference held in March 2013, Just because Vanderbilt has an EHR doesn't mean that everyone uses it, adding that being completely electronic doesnt necessarily equate with meaningful use.6 She also noted that the homegrown nature of their EHR led to department customization and wide variation in workflows and use. So, along with timing and technological challenges, there were also cultural challenges to achieving meaningful use.
Meeting the Challenges of Stage 2: Key Considerations
For those organizations that chose the easy way out as a path to financial gain, certain areas will present a greater challenge in Stage 2. The use of the Problem List and Medication Reconciliation are key measures that were meant to lay the foundation for population health management, patient safety, shared risk and patient engagement. The challenges identified for adequate capture of CQMs in MU Stage 1 have been well documented and will be compounded in Stage 2. Additional complications will face those who have continued to rely on disparate, non-integrated systems and those who did not do a deep dive on their data analysis. Then too there is the vendor reliance issue. Most all organizations are subject to reliance on the functionality and MU reports provided by their chosen vendor. Yet home-grown systems are not an easy alternative, as has been discovered by those who have struggled to self-certify and writ